1.5 ANCC Contact Hours Abstract Background: Swaddling has been practiced since antiquity; however, there is controversy about its safety. Objectives: The purpose of this review is to up- date and build upon previous reviews and synthe- size evidence on risks and benefi ts of swaddling in healthy-term, near-term, or older infants. Data Sources: MEDLINE (1960–May 13, 2016) and CINAHL (1963–May 13, 2016) searches were conducted, relevant articles retrieved, and citation lists reviewed for other references. Synthesis Methods: A table summarizes study details. Selected older references and supporting literature are integrated into the synthesis to provide context. Results: Swaddling calms infants and pro- motes sleep, but it is equally or less effective than other nonpharmacological methods in managing pain. There may be a slight risk for sudden infant death syndrome associated with supine swaddling, although the impact of confounding variables is unclear. Early skin-to-skin contact supports early breastfeed- ing, but swaddling does not have a negative impact on breastfeeding long term. Swaddling tightly around the hips is strongly associated with developmental dysplasia of the hip. More research is needed on the impact of swad- dling on pain in term infants, infant vital signs, arousal thresholds, and a possible association between swaddling, vitamin D defi ciency, and acute lower respiratory tract infection. Limitations: The number of studies was small, withwith ffewew ranrandomizedd control trials, and research- ers used differentdiffee defi nitions of swaddling. RISKS AND Conclusions:Conclusions If a few precautions are taken, BENEFITS OF susuchc as swaddling securely to mini- mize risk of unwrapping, avoiding overheating, placing infants to sleep supine, and discontinuing swaddling when infants fi rst show signs of rolling over, swad- dling presents minimal risk. ClinicalC Implications: Maternity to oto hot ho h SwaddlingHEALTHY INFANTS andand nneonatal nurses should model ckc P o to swaddlingsswwaadddling ppracticesra based on the evidence St and promote informed decision-making among An Integrative Review infant caregivers. Key Words: Evidence-based practice; Infant; ANTONIA M. NELSON, RNC-MNN, PhD, CNE, IBCLC Review Literature; Risks and benefi ts. Elly Godfroy / Alamy Stock Photo Stock Alamy Elly Godfroy /

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. t is widely acknowledged that swaddling of Risks and Benefi ts of Swaddling infants has been practiced since antiquity Psychological and (Frenken, 2011, 2012; Lipton, Steinschnei- Developmental Impact der, & Richmond, 1965; Moss & Solomons, Psychologist Frenken (2011) famously opined that the 1979). Use of tight, traditional swaddling impact of swaddling on the “development of the self” can practices, which tended to immobilize infants “only be negative” (p. 101). Although noting that there is in a mummy-like confi guration, decreased dramatically in sparse research evidence related to the psychological and theI Western world in the 18th century after being widely developmental impact of swaddling, his expert opinion condemned by the medical establishment (Dewees, 1847). originates from the supposed passivity, sensory depriva- Traditional practices, however, have continued among some tion, and suppression of mother and infant communica- indigenous people (Chisholm, 1978; Wilson, 2000) and tion that he believes swaddling promotes. Pediatrician in other areas of the world including: Russia (Bystrova Harvey Karp (2015) strongly disagrees with Frenken et al., 2007a, 2007b), Czechoslovakia (Beal & Porter, (2011). He suggests that swaddling is the “cornerstone of 1991), Turkey (Alparslan & Demırel, 2013; Yilmaz et al., calming” and suggests that parents swaddle their infants 2012), Arabia (Abdulrazzaq, Kendi, & Nagelkerke, during fussy periods and at times of sleep up to 4 to 2008), Japan (Yamamuro & Ishida, 1984), India (Iyengar, 5 months old (Karp, 2015, p. 100). Iyengar, Martines, Dashora, & Deora 2008), and Asia Based on recent research evidence, swaddling is equally (Li et al., 2000). effective in decreasing excessive crying af- Over time the method used and popu- ter 1 week as is introduction of regularity, larity of swaddling have varied dependent stimulus reduction, and uniformity into on culture, although recently a renewed an infant’s daily care. Swaddling appears interest in swaddling has emerged world- Swaddling to offer a more immediate effect and larg- wide. Swaddling has even been incorpo- er decrease in crying among younger rated into a popular program designed to soothes infants infants (Blom, van Sleuwen, de Vries, calm infants and promote longer sleep Engelberts, & L’Hoir, 2009; van Sleuwen (Karp, 2015). However, debate continues and promotes et al., 2006). Early swaddling has also among contemporary professionals as sleep. been found to decrease a mother’s re- to whether or not swaddling is safe sponsiveness to her infant, positive affec- and should be recommended (Goodstein, tive involvement, and dyad mutuality and Hauck, Darnall, Feldman-Winter, & reciprocity at 1 year (Bystrova et al., Moon, 2016; Kennedy, 2013). 2009). These effects may be because swaddling can some- what limit interaction between mother and infant. Search Strategy There is little research on the long-term physical and The objectives of this literature review were to update developmental impact of swaddling on infants. In an of- and build upon previous reviews (Frenken, 2011, 2012; ten cited observational study, Dennis and Dennis (1991) Lipton et al., 1965; Moss & Solomons, 1979; van found that Hopi Indian children swaddled and restrained Sleuwen et al., 2007), and summarize evidence on risks on a cradle board were no slower to walk than infants and benefi ts of swaddling for practicing maternity and whose mothers did not use a cradle board. More recently, newborn nurses. MEDLINE (1960–May 13, 2016) and Manaseki-Holland et al. (2010) found no signifi cant dif- CINAHL (1963–May 13, 2016) database searches were ferences in mental and psychomotor development at 11 to conducted using the key word swaddle. International and 17 months of age between infants swaddled for 7 months multidisciplinary human subject research (any level of and those who had not been swaddled. To date, the sparse design), retrospective analysis of human studies, or meta- evidence does not suggest that swaddling has a negative analyses related to risks and benefi ts of swaddling in impact on infant psychological or physical development. healthy full-term, near-term, or older infants were then identifi ed, retrieved, and screened (Figure 1). No quality Pain Management ratings were used to screen the resources retrieved. Cita- Researchers have investigated the effi cacy of swaddling to tions describing incidence or type of swaddling in a region comfort infants in pain. Pillai Riddell et al. (2011) in a meta- without making a comparison to nonswaddled infants, analysis concluded that there is enough evidence to recom- or reference to an outcome, were excluded. Citation lists mend swaddling and facilitated tucking to mediate pain were also reviewed to identify other potentially valuable reactivity in preterm but not in full-term infants. However, material. swaddling has been found to have some effect on full- To synthesize the research, notes were taken on all full- term infants in pain. For example, Morrow, Hidinger, and text articles retrieved, and a summary table created with Wilkinson-Faulk (2010) found that pain scores for infants study details of all sources that met the inclusion criteria. receiving a heel lance were signifi cantly lower in infants Selected older seminal references and supporting literature swaddled and held in an upright position than infants in were integrated into the evidential summary to provide the standard care position. However, Wisdorf-Houtkooper needed context. Details of the studies included in this re- (1997) found no difference in behavioral state, crying dura- view may be found in Supplemental Digital Content 1, tion, or facial expression during or after immunization when http://links.lww.com/MCN/A38. comparing pacifi er, rocking, swaddling, or control groups.

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. FLOW DIAGRAM OF ARTICLE SELECTION their infants in the supine rather than prone po- Figure 1. sition for sleep (Oden et al., 2012). Even older Records identifi ed from infants unaccustomed to swaddling accept su- Additional records identifi ed pine sleeping when swaddled. Perhaps because MEDLINE and CINAHL through other sources swaddling is calming, it may help infants accept database searches (n = 59) the supine sleep position (Gerard, Harris, & (n = 394) Thach, 2002). Swaddling may thus indirectly de- crease SIDS risk by promoting supine sleeping. Finally, the soothing and warming effect of Records after duplicates Records excluded with reasons swaddling has raised concern among some ex- removed (n = 223) perts who fear that swaddling may increase SIDS risk because decreased arousal and overheating (n = 372) 45 = commentary/ brief report are theorized to be implicated in SIDS etiology 103 = N/A to swaddling risks/ (Kleemann, Schlaud, Poets, Rothämel, & Tröger, benefi ts 1996; Richardson, Walker, & Horne, 2009). 42 = premature/ not healthy Records screened through Evidence related to these hypotheses is presented Title/ Abstracts 28 = descriptive cultural in the following sections. (n = 372) 5 = animal research Infant Arousability, Sleep, and Vital Signs Swaddled infants experience reduced sponta- neous awakening and arousability, greater quiet Full-text articles assessed for Full-text records excluded sleep, decreased time awake, and increased eligibility with reasons sleep effi ciency (Franco et al., 2005; Meyer & (n = 149) (n = 106) Erler, 2011; Richardson et al., 2009, 2010). 9 = commentary/ brief report Franco et al. (2005) however found that 64 = N/A to swaddling risks/ swaddled infants required less intense auditory benefi ts Studies included in qualitative stimuli to induce cortical arousal, whereas synthesis 3 = premature/ not healthy Richardson et al. (2009, 2010) found increased (n = 44) 15 = descriptive cultural arousal thresholds, decreased spontaneous 1 = animal research arousability, and heart rate variability in 14 = reviews 3-month-old infants naïve to swaddling but not in routinely swaddled infants. Franco, Scaillet, Groswasser, and Kahn (2004) found that swaddling decreased heart Breastfeeding and kangaroo mother care have also rate, but only in the supine position. Gerard et al. (2002) been found to be more effective in decreasing immediate found that only a tight, traditional swaddle as compared procedural pain than swaddling (Fallah, Naserzadeh, with a looser swaddle caused heart rates to lower. Tight Ferdosian, & Binesh, 2016; Hashemi, Taheri, Ghodsbin, swaddling caused infant respiratory rates to increase dur-

Pishva, & Vossoughi, 2016). In addition, heart rate and ing quiet sleep, although PaO2 level were unchanged. crying have been found to decrease more among new- Richardson et al. (2009, 2010) found that respiratory borns given a pacifi er along with oral glucose following rate increased with swaddling although they report no a heelstick than in those given oral glucose and swaddled change in baseline heart rate, temperature, or oxygen (Leng et al., 2016). Finally, pain has been found to de- saturation (Gerard et al., 2002). In contrast, Narangerel, crease following a heelstick more rapidly among infants Pollock, Manaseki-Holland, and Henderson (2007) given a pacifi er than in those swaddled (Campos, 1989). found although the respiratory rate of habitually swad- Evidence to date suggests although swaddling can have a dled infants was lower than in those habitually nonswad- calming effect on full-term infants in pain, it may not be dled, swaddling had no signifi cant clinical effect on SaO2 superior to other nonpharmacological measures. in healthy 9- to 10-week old infants. Research about the impact of swaddling on arousability and vital signs is Sudden Infant Death Syndrome (SIDS) unclear, and further research is needed. Evidence on swaddling and associated SIDS risk is equivo- cal. Avoidance of the prone or side infant sleeping posi- Thermoregulation tions and placing infants supine to sleep is now a widely Bystrova et al. (2003) found prolonged skin-to-skin con- accepted recommendation to reduce risk of SIDS (Ameri- tact between mother and infant beginning soon after can Academy of Pediatrics Task Force on Sudden Infant birth was more effective than swaddling in supporting Death Syndrome, 2011, 2016). However, some parents transitional newborn thermoregulation. Risk of over- report not placing their infants to sleep supine because of heating related to swaddling however, is the concern re- the perception that their infants are more comfortable lated to SIDS risk. Bundling infants in two blankets and prone (Colson et al., 2006, 2005). Parents who swaddle a hat has been found to signifi cantly increase skin but not their infants have been found to be more likely to place rectal temperature when compared with unwrapped

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. infants (Grover et al., 1994). A rise in body temperature limitations to their analysis including variability in preva- into the febrile range however, has been documented in lence of swaddling between studies, a lack of a precise newborn infants extremely overwrapped in fi ve blankets defi nition of swaddling, and inability to adjust for signifi - and a hat (Cheng & Partridge, 1993), suggesting it is pos- cant factors associated with SIDS risk such as bed-sharing. sible to overheat an infant through excessive swaddling. Thus, it cannot be defi nitively concluded that swaddling Fleming et al. (1990) found that overheating with heavy independently increases SIDS risk, although the evidence is wrapping in clothes and bedding of >10 tog (thermal clear that swaddled infants should always be placed to value) were independently associated with an increased sleep supine and hyperthermia should be avoided. risk of SIDS (RR 1.14 per tog above 8 tog), especially in infants aged 70 days or greater, and those sleeping prone. Breastfeeding Also, Ponsonby, Dwyer, Gibbons, Cochrane, and Wang Swaddling newborns is often discouraged by breastfeeding (1993) found that swaddled infants sleeping prone had a experts due to concerns that it may interfere with early ma- 12-fold increased SID risk. This may be because infants ternal–infant interactions, feeding cues, breastfeeding op- sleeping prone experience less heat loss than nonprone portunities, and milk production (Mohrbacher, 2010). sleeping infants (Tuffnell, Petersen, & Wailoo, 1995). Newborns placed skin-to-skin during the fi rst 2 hours after Ill infants are at particular risk for hyperthermia. Those birth rather than being swaddled have been found to have over 70 days old with a viral infection and clothing/bedding higher mean sucking competence during the fi rst breast- with a tog value of greater than 10 togs have been reported feeding and to breastfeed sooner (Moore & Anderson, to have an increased risk of death 2007). Also, early bathing followed (odds ratio of 51.1) (Gilbert et al., by swaddling has been found to de- 1992), perhaps because infants old- crease the demonstration of infant er than 3 months are more likely to feeding cues (Jansson, Mustafa, experience an increase in metabolic Khan, Lindblad, & Widström, rate and become febrile at night 1995). Finally, traditional swad- than younger infants (Fleming, dling at birth has been correlated Howell, Clements, & Lucas, 1994). with decreased infant “wakeful- Inadvertent head covering is also ness” during a breastfeeding 4 days a concern associated with swad- after birth and a rougher maternal dling and an important consider- affective response (Dumas et al., ation in relation to hyperthermia 2013, p. 322). and SIDS risk. In a meta-analysis of Despite the short-term impact of 10 population-based, age-matched, skin-to-skin contact on breastfeeding controlled studies reporting on head neither swaddling nor skin-to-skin covering among SIDS victims, Blair, contact have been found to indepen- Mitchell, Heckstall-Smith, and Flem- dently predict differences in breast- ing (2008) found the population- feeding outcomes, problems, recovery attributable risk was 27.1%, of infant weight loss postbirth, milk indicating that head covering is a production, or duration of nearly SIDS-related risk for infants. They exclusive breastfeeding for the fi rst theorized that an infant’s head is a 12 months (Bystrova et al., 2007a, major source of heat production 2007b; Moore & Anderson, 2007). and loss, and may contribute to hy- A full-term breastfeeding initiation perthermia, especially in the prone rate of 91.2% within 1 hour of position (Fleming, Azaz, & Wig- birth, and average breastfeeding Thomas Baker / Alamy Stock Photo Stock Alamy Thomas Baker / fi eld, 1992; Fleming, Levine, Azaz, duration of 19 months, has been Wigfi eld, & Stewart, 1993). reported among refugee women in Results of a meta-analysis of Evidence on the impact Thailand. In this culture moderately four case-control studies judged to snug swaddling, breastfeeding, and be of good quality based on the of swaddling on infant rooming-in are widely practiced and Newcastle-Ottawa Scale (Wells et supported (White et al., 2012), al., 2014) found an increased risk arousal thresholds and suggesting swaddling does not nec- of SIDS with increasing age, and vital signs is unclear. essarily have a negative impact on greatest risk among swaddled in- breastfeeding within a strongly sup- fants 6 months or older (Pease et al., portive environmental context. 2016). They also found that the prone or side-lying position greatly increased SIDS risk Developmental Dysplasia of the Hip among swaddled infants. Being swaddled and placed to The correlation between swaddling and an increased bed supine, however, was still found to be associated with risk of developmental dysplasia of the hip (DDH) is “a small but signifi cant risk” when compared with con- clear (Loder & Skopelja, 2011). This association is trols (Pease et al., p. 6). The authors acknowledged many strongly supported by fi ndings that DDH is high among

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. swaddled infants in cultures where they use various An alternative explanation for an association between forms of swaddling that are tight around the hips such tight swaddling and ARI is that ARI in swaddled infants as in Turkey (Akman et al., 2007; Dogruel, Atalar, may be related to decreased sun exposure and associated Yavuz, & Sayli, 2008; Guner et al., 2013; Kutlu, Me- subclinical vitamin D level (rickets). Acute lower respiratory mik, Mutlu, Kutlu, & Arslan, 1992), Saudi Arabia (Abd infection (ALRI) has been found to be associated with rick- El-Kader Shaheen, 1989; Kremli, Alshahid, Khoshhal, ets in Indian children in the fi rst 4 months of life, especially & Zamzam, 2003), and Japan (Ishida, 1977). The inde- among infants swaddled when exposed to sunlight (Wayse, pendent association between DDH and swaddling is Yousafzai, Mogale, & Filteau, 2004). Mean vitamin D con- supported by the dramatic effectiveness of campaigns to centrations have also been shown to be lower in a group of change these traditional infant infants admitted to a neonatal unit care practices in decreasing hip for ALRI than in control infants abnormalities (Chaarani, Mahmeid, (Karatekin, Kaya, Salihog˘lu, Balci, & Salmon, 2002; Ishida, 1977). & Nuhog˘lu, 2009). See Supplementary Digital Content 1, Most studies demonstrate that http://links.lww.com/MCN/A3 for vitamin D has a protective effect study details. against respiratory tract infections The prevailing view for decades in adults and school age children has been that tight swaddling likely (Bergman, Lindh, Björkhem- does not “cause” DDH rather that Bergman, & Lindh, 2013; Gröber, it might worsen the condition in Spitz, Reichrath, Kisters, & Holick, those infants who are genetically 2013; Laaksi, 2012). Rickets have predisposed (Salter, 1968). This been found to be strongly associat- view is supported by the almost ed with pneumonia in studies nonexistent incidence of DDH in conducted in the developing world populations such as the African (Lubani et al., 1989; Muhe, country of Malawi, where infants Lulseged, Mason, & Simoes, are not swaddled, but rather “back 1997). However, Urnaa et al. carried” from 2 to 6 weeks until 18 (2006) found no association be- to 24 months of age (Graham, tween duration of swaddling and Manara, Chokotho, & Harrison, rickets or bone properties of school 2015). The back-carrying practice age children. Current evidence does promotes infant hip fl exion and ab- not suggest a direct link between duction, rather than the hip adduc- swaddling and ARI and develop- tion caused by tight swaddling. ment of rickets; however, more In a study using sonographic research is needed on a possible as- technology using a group of in- Providing skin-to-skin sociation between swaddling, vita- fants being treated for DDH, min D defi ciency, and ALRI. Harcke, Karatas, Cummings, and care postbirth rather than Bowen (2016) objectively demon- swaddling promotes early Swaddling Safety strated that tight swaddling limit- and Professional ed hip fl exion/abduction and even breastfeeding, but swaddling dislocated one unstable hip. When Safe Infant Sleep safe hip-healthy swaddling (loose has no long-term negative Recommendations around the hips) was used, there In 2011, the American Academy was no limitation of hip fl exion impact on breastfeeding. of Pediatrics (AAP) published rec- and abduction, and no change in ommendations for a Safe Infant hip stability. This suggests, not all Sleeping Environment (AAP Task swaddling techniques place infants at an increased risk Force on SIDS, 2011), which were recently updated (AAP of DDH. Task Force on SIDS, 2016). In the latest report “Level A” recommendations (U.S. Preventive Services Task Force, Respiratory Infection, Vitamin D Defi ciency, and Rickets 2014), based on consistent results from well-done studies, Other potential swaddling risks currently under investiga- include: back to sleep for every sleep (supine sleep posi- tion are an increased risk of acute respiratory infection tioning), use of a fi rm sleep surface, breastfeeding, room- (ARI) and vitamin D defi ciency (rickets). In one large de- sharing without bed-sharing, keeping soft objects and scriptive study in Turkey where tight swaddling is still loose bedding out of the crib, and avoiding overheating common, Yurdakok, Yavuz, and Taylor (1990) found ba- (AAP Task Force on SIDS, 2016, p. 2). Within these bies swaddled for a minimum of 3 months were four times guidelines AAP addresses swaddling and safe infant sleep. more likely to develop pneumonia and ARI than babies The AAP Task Force on SIDS (2016) position on who were not swaddled, perhaps because tight swaddling swaddling is that “there is no evidence to recommend promotes shallow breathing and restricts lung expansion. swaddling as a strategy to reduce the risk of SIDS” (p. 7).

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Table 1. SUMMARY OF EVIDENCE FOR SWADDLING RISKS AND BENEFITS Risk or Benefi t Level of Evidence Developmental • One randomized control trial (RCT) found swaddling equally effective as uniformity of care in managing impact crying (Blom et al., 2009; van Sleuwen et al., 2006) • One RCT found a negative effect of swaddling on the early mother–infant relationship at 1 year when compared with early skin-to-skin contact (Bystrova et al., 2009) • One observational study found no difference between swaddled and nonswaddled infants related to walking (Dennis & Dennis, 1991), and one RCT found no impact on mental/psychomotor development (Manaseki-Holland et al., 2010) • Some experts have expressed concern swaddling may negatively impact development of a self-concept, whereas others praise the calming/soothing effect of swaddling (Frenken, 2011; Karp, 2015)

Pain • A fi nding from meta-analysis of RCTs concluded that there is enough evidence to recommend the use management of swaddling for pain management in preterm infants, but not full-term infants (Pillai Riddell et al., 2011) • RCTs suggest swaddling is somewhat useful in pain management for full-term infants, equally effective or less effective than other nonpharmacological measures (Campos, 1989; Fallah et al., 2016; Hashemi et al., 2016; Leng et al., 2016; Morrow et al., 2010; Wisdorf-Houtkooper, 1997) Sudden • A meta-analysis of four case-control studies found a signifi cant increase in SIDS risk associated with infant death age, and the prone or side-lying sleep position. A slight increase was associated with swaddling and syndrome supine sleeping, although all confounding variables were not accounted for (Pease et al., 2016) • A nonexperimental and a quasi-experimental study suggest swaddling may support supine sleeping (Gerard et al., 2002; Oden et al., 2012)

Infant Arousability/Vital Signs/Sleep • RCT and quasi-experimental studies report swaddling improves sleep effi ciency although impact on arousability and vital signs remains unclear, and changes in PaO2 levels have not been reported (Franco et al., 2004, 2005; Meyer & Erler, 2011; Narangerel et al., 2007; Richardson et al., 2009, 2010) • Some experts question whether decreased arousability among swaddled infants may increase SIDS risk (Richardson et al., 2009) Thermoregulation • One RCT supports early use of skin-to-skin versus swaddling for infant thermoregulation (Bystrova et al., 2003) • One randomized, prospective study found that swaddling increased skin temperature but not rectal temperature (Grover et al., 1994) • A quasi-experimental study suggests that extreme overwrapping can cause abnormal increases in temperature (Cheng & Partridge, 1993) • Case-control, prospective cohort, and descriptive studies suggest that older infants placed prone, overwrapped, and/or experiencing a fever are at increased risk of SIDS (Fleming et al., 1990; Gilbert et al., 1992; Ponsonby et al., 1993) • A meta-analysis of population-based controlled studies concluded that head covering constitutes a signifi cant SIDS risk (Blair et al., 2008) • Some experts question whether swaddling-associated hyperthermia may increase SIDS risk (Kleemann et al., 1996) Breastfeeding • RCTs and descriptive studies report swaddling negatively impacts short-term breastfeeding outcomes (Dumas et al., 2013; Moore & Anderson, 2007), though it has no independent, long-term negative impact (Bystrova et al., 2007a, 2007b; Jansson et al., 1995; Moore & Anderson; White et al., 2012) • Experts suggest swaddling may interfere with maternal–infant interactions, feeding cues, breastfeeding opportunities, and milk production (Mohrbacher, 2010)

Developmental • Quasi-experimental and descriptive studies have consistently reported that tight swaddling is strongly hip dysplasia associated with DDH (Abd El-Kader Shaheen, 1989; Akman et al., 2007; Dogruel et al., 2008; Guner et al., 2013; Kremli et al., 2003; Kutlu et al., 1992) • Two large quasi-experimental studies demonstrated a steady decrease in hip abnormalities with an educational intervention (Chaarani et al., 2002; Ishida, 1977) • One quasi-experimental pilot study found tight swaddling limited hip fl exion/abduction and that “ hip-healthy” swaddling did not (Harcke et al., 2016)

Respiratory • One large descriptive study found pneumonia/upper respiratory infection more likely in tightly swaddled infection/ infants (Yurdakok et al., 1990) Rickets • Evidence from case-control studies does not support a direct causal link between swaddling and rickets (Urnaa et al., 2006) although subclinical vitamin D defi ciency has been found to be a signifi cant risk factor for ALRI (Wayse et al., 2004)

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. SUGGESTED CLINICAL IMPLICATIONS The AAP has also published a report related to safe sleep • Swaddling may be used as a means to calm and sooth and skin-to-skin for healthy-term newborns in hospitals infants and promote sleep and birthing centers (Feldman-Winter, Goldsmith, Committee on Fetus and Newborn, & Task Force on SIDS, 2016). • Hyperthermia should be avoided through securely Recommendations are offered for improving safety while swaddling with a single blanket of low tog value, using swaddling with caution in infants with a fever, and always rooming-in and decreasing risk infant falls and sudden un- placing swaddled infants to sleep in the supine position expected postnatal collapse, mostly related to suffocation or entrapment. These recommendations include: nurse-to- • Swaddling may be used between periods of skin-to-skin mother–baby couplet ratios that permit routine monitoring care when an infant is placed for safety on their own based on level of risk, education related to the risks of bed- sleep surface to help maintain infant thermoregulation and comfort sharing, and available assistance to transition newborns to a safe sleep location as needed when the mother is not • Swaddling should always be “hip healthy” and allow for awake and alert (Feldman-Winter et al.). During the new- hip abduction born period in the hospital, swaddling an infant and plac- • Swaddled infants who are breastfeeding may need to be ing them in their own bed may be appropriate. awakened at appropriate intervals if not spontaneously Specifi c guidelines are also available related to swad- awaking until an adequate feeding pattern is established dling outside of the home environment. The AAP along • The American Academy of Pediatrics safe infant sleep with the National Resource Center for Health and Safety recommendations should be followed for all infants in Child Care and Education, and the American Public Health Association, published the third edition of their • Swaddling should be discontinued when infants fi rst safety guidelines for child-care settings (2011). These show signs of rolling over guidelines state that, “In childcare settings swaddling is not necessary or recommended” (para. 1), and “If swad- They further recommend if swaddling is used, the infant dling is used, it should be used less and less over the course should always be placed supine to sleep, swaddling of the fi rst few weeks and months of an infant’s life” should be snug around the chest but allow room for (para. 3). The panel expressed concern that older children movement around the hips and knees [related to the risk in child care with multiple caregivers, learning to roll of hip dysplasia], and swaddling should be discontinued over, are more diffi cult to swaddle safely (AAP, 2013). when infants fi rst show signs of rolling over (AAP Task This clarifi cation suggests that all swaddling guidelines Force on SIDS, 2016, p. 7). need to be considered within the appropriate context. The AAP Task Force on SIDS (2016) recommendation on when to discontinue swaddling is related to the recent Discussion and Implications for Practice publication by McDonnell and Moon (2014) who retro- There are a number of important limitations to any inte- spectively reviewed cases of 10 infant deaths related to grative review on infant swaddling. There are few studies wearable blankets or swaddle wraps, and 12 deaths relat- and no large randomized control trials; thus, the level of ed to swaddling in blankets reported to the Consumer evidence related to risks and benefi ts is generally not Product Safety Commission between 2004 and 2014. One strong (Table 1). The exception is evidence related to of these deaths was attributed to hyperthermia, one was DDH, although primarily descriptive, has consistently placed prone to sleep, and six rolled into the prone posi- suggested a strong association between DDH and swad- tion while swaddled. These fi ndings highlight risks associ- dling that is tight around the hips. ated with placing swaddled infants prone and swaddling Another limitation of this body of work is that research- older infants. It should be noted among deaths associated ers use vastly different defi nitions of “swaddling;” therefore, with swaddling only one was not related to environmental any summary of evidence must be viewed with caution. risks such as blankets, pillows, and bumper pads, support- Some of the most serious potential risks of swaddling such ing importance of always adhering to Safe Infant Sleeping as an increased rate of ARI and DDH seem to only be as- Environment guidelines (AAP Task Force on SIDS, 2016). sociated with tight swaddling. However, the degree of Risk of DDH associated with swaddling has been tightness that puts infants at risk is uncertain. Overall, it is addressed through a joint statement from AAP, Pediatric logical that quality of caregiving provided, individual Orthopaedic Society of North America (POSNA), Interna- characteristics of the infant, degree of swaddling tightness, tional Hip Dysplasia Institute (IHDI), and American number of hours a day an infant is swaddled, and length Academy of Orthopaedic Surgeons that recommends of time swaddling is continued, all infl uence the relative “hip-healthy swaddling” if parents chose to swaddle their risk-benefi t ratio of swaddling. infants (POSNA, 2015). This type of swaddling allows the Despite limitations of the swaddling literature, there are infant’s legs “to bend up and out at the hips” and not important clinical practice implications from this review. “tightly wrapped straight down and pressed together” These are summarized in Suggested Clinical Implications. (IHDI, Are You Swaddling Your Baby Properly?, para. Maternity and neonatal nurses in the clinical setting should 3–4). The IHDI recommends sleep sacks only if they have strive to model swaddling best practices, derived from cur- a “loose pouch or sack” for the infant’s legs and feet, rent evidence, and provide evidence-based education for which allow hip movement (IHDI, What about sleepsacks caregivers. A variety of sources are available in print and and commercial products, para. 1). online that offer instructions for safe, secure infant

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. swaddling. One is the Down-Up-Down-Up “DUDU” Alparslan, Ö., & Demırel, Y. (2013). Traditional neonatal care practices in Turkey. Japan Journal of Nursing Science, 10(1), 47-54. doi:10.1111 / wrap technique described by (Karp, 2004, 2015, pp. 114– j.1742-7924.2012.00209.x 117). A video demonstrating three “hip healthy” ways to American Academy of Pediatrics. (2013). Swaddling: Is it safe? Re- swaddle is available on the IHDI Web site: http://hipdy trieved from https://healthychildren.org American Academy of Pediatrics, American Public Health Association, splasia.org/developmental-dysplasia-of-the-hip/hip- & National Resource Center for Health and Safety in Child and Early healthy-swaddling/. All healthcare professionals and family Education. (2011). Chapter 3: Health promotion and protection Stan- dard 3.1.4.2: Swaddling. In Caring for our children: National health members should understand the importance of adhering to and safety performance standards; Guidelines for early care and the AAP guidelines for safe infant sleep (AAP Task Force education programs (3rd ed.). Retrieved from http://cfoc.nrckids. on SIDS, 2016; Feldman-Winter et al., 2016). org/StandardView/3.1.4.2 American Academy of Pediatrics Task Force on Sudden Infant Death Syn- Finally, the evidence does not suggest that swaddling has drome. (2011). SIDS and other sleep-related infant deaths: Expansion an independent, long-term negative impact on breastfeed- of recommendations for a safe infant sleeping environment. Pediat- ing, and judicious use of swaddling does not preclude skin- rics, 128(5), 1030-1039. doi:10.1542/peds.2011-2284 American Academy of Pediatrics Task Force on Sudden Infant Death Syn- to-skin time between mother and infant. Whether or not an drome. (2016). SIDS and other sleep-related infant deaths: Updated infant is swaddled, attention should be paid to the number 2016 recommendations for a safe infant sleeping environment. Pedi- atrics, 138(5), 1-12. doi:10.1542/peds.2016-2938 of times an infant is feeding per day, infant output, and Beal, S., & Porter, C. (1991). Sudden infant death syndrome related to weight gain (Wambach & Riordan, 2016). This may mean climate. Acta Paediatrica Scandinavica, 80(3), 278-287. that swaddled infants, who do not regularly wake on their Bergman, F., Lindh, A. U., Björkhem-Bergman, L., & Lindh, J. D. (2013). Vitamin D and respiratory tract infections: A systematic review and own to feed, may need to be awakened at appropriate in- meta-analysis of randomized controlled trials. PloS one, 8(6), tervals until an adequate growth pattern has been estab- e65835, 1-6. doi:10.1371/journal.pone.0065835 lished. Evidence that mothers of colicky infants report Blair, P. S., Mitchell, E. A., Heckstall-Smith, E. M., & Fleming, P. J. (2008). Head covering—A major modifi able risk factor for sudden infant breastfeeding for a shorter duration than those of noncol- death syndrome: A systematic review. Archives of Diseas in Child- icky infants may indirectly suggest if swaddling can calm a hood, 93(9), 778-783. doi:10.1136/adc.2007.136366 colicky infant it may prolong breastfeeding in some infants Blom, M. A., van Sleuwen, B. E., de Vries, H., Engelberts, A. C., & L’Hoir, M. P. (2009). Health Care interventions for excessive crying in infants: (Howard, Lanphear, Lanphear, Eberly, & Lawrence, 2006). Regularity with and without swaddling. Journal of Child Health Care, More research is needed on the impact of swaddling on 13(2), 161-176. doi:10.1177/1367493509102476 Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A. S., Ransjö- infant arousal and vital signs, effectiveness of swaddling Arvidson, A. B., Mukhamedrakhimov, R., …, Widström, A. M. (2009). to mediate pain responses in healthy-term newborns, and Early contact versus separation: Effects on mother-infant interaction a possible association between swaddling, vitamin D defi - one year later. Birth, 36(2), 97-109. doi:10.1111/j.1523-536X.2009.00307.x Bystrova, K., Matthiesen, A. S., Widström, A. M., Ransjö-Arvidson, A. B., ciency and ALRI. This review is an evidence-based sum- Welles-Nyström, B., Vorontsov, I., & Uvnäs-Moberg, K. (2007a). The mary of the risks, benefi ts, and recommendations related effect of Russian Maternity Home routines on breastfeeding and to swaddling as available in current literature. Through neonatal weight loss with special reference to swaddling. Early Hu- man Development, 83(1), 29-39. doi:10.1016/j/earlhumdev.2006.03.016 modeling swaddling best practices and providing evi- Bystrova, K., Widström, A. M., Matthiesen, A. S., Ransjö-Arvidson, A. B., dence-based teaching, nurses are in a position to foster Welles-Nyström, B., Vorontsov, I., & Uvnäs-Moberg, K. (2007b). Early lactation performance in primiparous and multiparous wom- informed decision-making among caregivers and promote en in relation to different maternity home practices. A randomised health and well-being of child-bearing families. ✜ trial in St. Petersburg. International Breastfeeding Journal, 2, 9-22. doi:10.1186/1746-4358-2-9 Bystrova, K., Widström, A. M., Matthiesen, A. S., Ransjö-Arvidson, A. B., Supplemental digital content is available for this article. Welles-Nyström, B., Wassberg, C., …, Uvnäs-Moberg, K. (2003). Skin-to- Direct URL citations appear in the printed text and are skin contact may reduce negative consequences of “the stress of being provided in the HTML and PDF versions of this article born”: A study on temperature in newborn infants, subjected to dif- ferent ward routines in St. Petersburg. Acta Paediatrica, 92(3), 320-326. on the journal’s Web site (www.mcnjournal.com). Campos, R. G. (1989). Soothing pain-elicited distress in infants with swaddling and pacifi ers. Child Development, 60(4), 781-792. Chaarani, M. W., Al Mahmeid, M. S., & Salman, A. M. (2002). Developmental Antonia M. Nelson is an Associate Professor of Nursing, dysplasia of the hip before and after increasing community awareness Saint Anselm College, Manchester, NH. The author can be of the harmful effects of swaddling. Qatar Medical Journal, 11(1), 40-43. reached via e-mail at [email protected] Cheng, T. L., & Partridge, J. C. (1993). Effect of bundling and high envi- ronmental temperature on neonatal body temperature. Pediatrics, 92(2), 238-240. The author has no funding sources or confl icts of inter- Chisholm, J. S. (1978). Swaddling, cradleboards and the development est to report. of children. Early Human Development, 2(3), 255-275. Colson, E. R., Levenson, S., Rybin, D., Calianos, C., Margolis, A., Colton, T., …, Corwin, M. J. (2006). Barriers to following the supine sleep Copyright © 2017 Wolters Kluwer Health, Inc. All rights recommendation among mothers at four centers for the women, reserved. infants, and children program. Pediatrics, 118(2), e243-e250. Colson, E. R., McCabe, L. K., Fox, K., Levenson, S., Colton, T., Lister, G., & DOI:10.1097/NMC.0000000000000344 Corwin, M. J. (2005). Barriers to following the back-to-sleep recom- mendations: Insights from focus groups with inner-city caregivers. References Ambulatory Pediatrics, 5(6), 349-354. Abd El-Kader Shaheen, M. (1989). Mehad: The Saudi tradition of infant Dennis, W., & Dennis, M. G. (1991). The effect of cradling practices upon wrapping as a possible aetiological factor in congenital dislocation of the the onset of walking in Hopi children. 1940. The Journal of Genetic hip. Journal of the Royal College of Surgeons of Edinburgh, 34(2), 85-87. Psychology, 152(4), 563-572. Abdulrazzaq, Y. M., Kendi, A. A., & Nagelkerke, N. (2008). Child care prac- Dewees, W. (1847). A treatise in the physical and medical treatment of tice in the United Arab Emirates: The ESACCIPS study. Acta Paedi- children (9th ed.). Philadephia, PA: Lea & Blanchard. Retrieved from atrica, 97(5), 590-595. doi:10.1111/j.1651-2227.2008.00758.x http://catalog.hathitrust.org/Record/008887700 Akman, A., Korkmaz, A., Aksoy, M. C., Yazici, M., Yurdakök, M., & Teki- Dogruel, H., Atalar, H., Yavuz, O. Y., & Sayli, U. (2008). Clinical examina- nalp, G. (2007). Evaluation of risk factors in developmental dyspla- tion versus ultrasonography in detecting developmental dysplasia sia of the hip: Results of infantile hip ultrasonography. The Turkish of the hip. International Orthopaedics, 32(3), 415-419. doi:10.1007/ Journal of Pediatrics, 49(3), 290-294. s00264-007-0333-X

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Dumas, L., Lepage, M., Bystrova, K., Matthiesen, A. S., Welles-Nyström, B., Iyengar, S. D., Iyengar, K., Martines, J. C., Dashora, K., & Deora, K. K. & Widström, A. M. (2013). Infl uence of skin-to-skin contact and room- (2008). Childbirth practices in rural Rajasthan, India: Implications ing-in on early mother-infant interaction: A randomized controlled trial. for neonatal health and survival. Journal of Perinatology, 28(Suppl. 2), Clinical Nursing Research, 22(3), 310-336. doi:10.1177/1054773812468316 S23-S30. do i:10.1038/jp.2008.174 Fallah, R., Naserzadeh, N., Ferdosian, F., & Binesh, F. (2016). Compari- Jansson, U. M., Mustafa, T., Khan, M. A., Lindblad, B. S., & Widström, A. son of effect of kangaroo mother care, breastfeeding and swad- M. (1995). The effects of medically-orientated labour ward routines dling on Bacillus Calmette-Guerin vaccination pain score in healthy on prefeeding behaviour and body temperature in newborn infants. term neonates by a clinical trial. The Journal of Maternal-Fetal & Journal of Tropical Pediatrics, 41(6), 360-363. Neonatal Medicine, published online June 30, 2016. doi:10.1080/14 Karatekin, G., Kaya, A., Salihog˘lu, O., Balci, H., & Nuhog˘lu, A. (2009). As- 767058.2016.1205030 sociation of subclinical vitamin D defi ciency in newborns with acute Feldman-Winter, L., Goldsmith, J. P., Committee on Fetus and Newborn, lower respiratory infection and their mothers. European Journal of & Task Force on sudden infant death syndrome. (2016). Safe sleep Clinical Nutrition, 63(4), 473-477. doi:10.1038/sj.ejcn.1602960 and skin-to-skin care in the neonatal period for healthy term new- Karp, H. (2004). How to swaddle your baby. Contemporary Pediatrics, borns. Pediatrics, 138(3), e1-e10. doi:10.1542/peds.2016-1889 21(2), 115-116. Fleming, P. J., Azaz, Y., & Wigfi eld, R. (1992). Development of thermoregu- Karp, H. (2015). The happiest baby on the block (2nd ed.). New York, NY: lation in infancy: Possible implications for SIDS. Journal of Clinical Bantam Books. Pathology, 45 (11 Suppl.), 17-19. Kennedy, K. (2013). Unwrapping the controversy over swaddling. AAP Fleming, P. J., Gilbert, R., Azaz, Y., Berry, P. J., Rudd, P. T., Stewart, A., & News, 34(6), 1-2. Hall, E. (1990). Interaction between bedding and sleeping position in Kleemann, W. J., Schlaud, M., Poets, C. F., Rothämel, T., & Tröger, H. D. the sudden infant death syndrome: A population based case-control (1996). Hyperthermia in sudden infant death. International Journal study. British Medical Journal, 301(6743), 85-89. of Legal Medicine, 109(3), 139-142. Fleming, P. J., Howell, T., Clements, M., & Lucas, J. (1994). Thermal balance Kremli, M. K., Alshahid, A. H., Khoshhal, K. I., & Zamzam, M. M. (2003). and metabolic rate during upper respiratory tract infection in infants. The pattern of developmental dysplasia of the hip. Saudi Medical Archives of Disease in Childhood, 70(3), 187-191. Journal, 24(10), 1118-1120. Fleming, P. J., Levine, M. R., Azaz, Y., Wigfi eld, R., & Stewart, A. J. (1993). Kutlu, A., Memik, R., Mutlu, M., Kutlu, R., & Arslan, A. (1992). Congeni- Interactions between thermoregulation and the control of respira- tal dislocation of the hip and its relation to swaddling used in Tur- tion in infants: Possible relationship to sudden infant death. Acta key. Journal of Pediatric Orthopedics, 12(5), 598-602. Paediatrica. Supplement, 82(Suppl. 389), 57-59. Laaksi, I. (2012). Symposium 4: Vitamins, infectious and chronic disease Franco, P., Scaillet, S., Groswasser, J., & Kahn, A. (2004). Increased car- during adulthood and aging Vitamin D and respiratory infection in diac autonomic responses to auditory challenges in swaddled in- adults. Proceedings of the Nutrition Society, 71, 90-97. doi:10.1017/ fants. Sleep, 27(8), 1527-1532. S0029665111003351 Franco, P., Seret, N., Van Hees, J. N., Scaillet, S., Groswasser, J., & Kahn, A. Leng, H. Y., Zheng, X. L., Zhang, X. H., He, H. Y., Tu, G. F., Fu, Q., …, Yan, L. (2005). Infl uence of swaddling on sleep and arousal characteristics of (2016). Combined non-pharmacological interventions for newborn healthy infants. Pediatrics, 115(5), 1307-1311. doi:10.1542/peds.2004-1460 pain relief in two degrees of pain procedures: A randomized clinical Frenken, R. (2011). Psychology and history of swaddling. Part one: Antiq- trial. European Journal of Pain, 20(6), 989-997. doi:10.1002/ejp.824 uity until 15th century. The Journal of Psychohistory, 39(2), 84-114. Li, Y., Liu, J., Liu, F., Guo, G., Anme, T., & Ushijima, H. (2000). Maternal Frenken, R. (2012). Psychology and history of swaddling. Part two: The child-rearing behaviors and correlates in rural minority areas of abolishment of swaddling from the 16th century until today. The Jour- Yunnan, China. Journal of Developmental and Behavioral Pediat- nal of Psychohistory, 39(3), 219-245. rics, 21(2), 114-122. Gerard, C. M., Harris, K. A., & Thach, B. T. (2002). Physiologic studies on Lipton, E. L., Steinschneider, A., & Richmond, J. B. (1965). Swaddling, a swaddling: An ancient child care practice, which may promote the child care practice: Historical, cultural and experimental observa- supine position for infant sleep. The Journal of Pediatrics, 141(3), tions. Pediatrics, 35(Suppl.), 519-567. 398-403. doi:10.1067/mpd.2002.127508 Loder, R. T., & Skopelja, E. N. (2011). The epidemiology and demographics Gilbert, R., Rudd, P., Berry, P. J., Fleming, P. J., Hall, E., White, D. G., …, of hip dysplasia. International Scholarly Research Network Orthope- Evans, J. A. (1992). Combined effect of infection and heavy wrap- dics, 2011, 1-46. doi:10.5402/2011/238607 ping on the risk of sudden unexpected infant death. Archives of Lubani, M. M., al-Shab, T. S., al-Saleh, Q. A., Sharda, D. C., Quattawi, S. Disease in Childhood, 67(2), 171-177. A., Ahmed, S. A., …, Reavey, P. C. (1989). Vitamin-D-defi ciency rick- Goodstein, M. H., Hauck, F. R., Darnall, R. A., Feldman-Winter, L., & ets in Kuwait: The prevalence of a preventable disease. Annals of Moon, R. Y. (2016). Swaddling is not contraindicated in the newborn Tropical Paediatrics, 9(3), 134-139. period. Journal of Perinatology, 36(2), 160. doi:10.1038/jp.2015.182 Manaseki-Holland, S., Spier, E., Bavuusuren, B., Bayandorj, T., Sprachman, Graham, S. M., Manara, J., Chokotho, L., & Harrison, W. J. (2015). Back- S., & Marshall, T. (2010). Effects of traditional swaddling on develop- carrying infants to prevent developmental hip dysplasia and its se- ment: A randomized controlled trial. Pediatrics, 126(6), e1485-e1492. quelae: Is a new public health initiative needed? Journal of Pediat- doi:10.1542/peds.2009-1531 ric Orthopedics, 35(1), 57-61. doi:10.1097/BPO.0000000000000234 McDonnell, E., & Moon, R. Y. (2014). Infant deaths and injuries associated Gröber, U., Spitz, J., Reichrath, J., Kisters, K., & Holick, M. F. (2013). Vitamin with wearable blankets, swaddle wraps, and swaddling. The Journal D: Update 2013: From rickets prophylaxis to general preventive health- of Pediatrics, 164(5), 1152-1156. doi:10.1016/j.jpeds.2013.12.045 care. Dermato-Endocrinology, 5(3), 331-347. doi:10.4161/derm.26738 Meyer, L. E., & Erler, T. (2011). Swaddling: A traditional care method re- Grover, G., Berkowitz, C. D., Lewis, R. J., Thompson, M., Berry, L., & discovered. World Journal of Pediatrics, 7(2), 155-160. doi:10.1007/ Seidel, J. (1994). The effects of bundling on infant temperature. Pe- s12519-011-0268-6 diatrics, 94(5), 669-673. Mohrbacher, M. (2010). Rethinking swaddling. International Journal of Guner, S. I., Guner, S., Peker, E., Ceylan, M. F., Guler, A., Turktas, U., & Childbirth Education, 25(3), 7-10. Kaki, B. (2013). Are consanguineous marriage and swaddling the Moore, E. R., & Anderson, G. C. (2007). Randomized controlled trial of risk factors of developmental dysplasia of the hip? The Journal of very early mother-infant skin-to-skin contact and breastfeeding sta- Membrane Biology, 246(2), 115-119. doi:10.1007/s00232-012-9509-4 tus. Journal of Midwifery & Women’s Health, 52(2), 116-125. doi:10. Harcke, H. T., Karatas, A. F., Cummings, S., & Bowen, J. R. (2016). Sono- 1016/j.jmwh.2006.12.002 graphic assessment of hip swaddling techniques in infants with Morrow, C., Hidinger, A., & Wilkinson-Faulk, D. (2010). Reducing neo- and without DDH. Journal of Pediatric Orthopedics, 36(3), 232-238. natal pain during routine heel lance procedures. MCN. The Ameri- doi:10.1097/BPO.0000000000000446 can Journal of Maternal Child Nursing, 35(6), 346-354. doi:10.1097/ Hashemi, F. Taheri, L., Ghodsbin, F., Pishva, N., & Vossoughi, M. (2016). NMC.0b013e3181f4fc53 Comparing the effect of swaddling and breastfeeding and their Moss, J., & Solomons, H. C. (1979). Swaddling then, there and now: combined effect on the pain induced by BCG vaccination in infants Historical, anthropological and current practices. Maternal-Child referring to Motahari Hospital, Jahrom, 2010-2011. Applied Nursing Nursing Journal, 8(3), 137-151. Research, 29, 217-221. doi:10.1016/j.apnr.2015.05.013 Muhe, L., Lulseged, S., Mason, K. E., & Simoes, E. A. (1997). Case-control Howard, C. R., Lanphear, N., Lanphear, B. P., Eberly, S., & Lawrence, R. study of the role of nutritional rickets in the risk of developing pneu- A. (2006). Parental responses to infant crying and colic: The effect on monia in Ethiopian children. Lancet, 349(9068), 1801-1804. breastfeeding duration. Breastfeeding Medicine, 1(3), 146-155. Narangerel, G., Pollock, J., Manaseki-Holland, S., & Henderson, J., (2007). International Hip Dysplasia Institute. Are you swaddling your infant The effects of swaddling on oxygen saturation and respiratory rate of properly? Retrieved from from http://hipdysplasia.org/ healthy infants in Mongolia. Acta Paediatrica, 96(2), 261-265. International Hip Dysplasia Institute. What about sleepsacks and com- doi:10.1111/j.1651-2227.2007.00123.x mercial products? Retrieved from from http://hipdysplasia.org/ Oden, R. P., Powell, C., Sims, A., Weisman, J., Joyner, B. L., & Moon, R. Ishida, K. (1977). Prevention of the development of the typical dislocation Y. (2012). Swaddling: Will it get babies onto their backs for sleep? of the hip. Clinical Orthopaedics and Related Research, (126), 167-169. Clinical Pediatrics, 51(3), 254-259. doi:10.1177/0009922811420714

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Pease, A. S., Fleming, P. J., Hauck, F. R., Moon, R. Y., Horne, R. S., L’Hoir, van Sleuwen, B. E., Engelberts, A. C., Boere-Boonekamp, M. M., Kuls, M. P., …, Blair, P. S. (2016). Swaddling and the risk of sudden infant W., Schulpen, T. E. J., & L’Hoir, M. P. (2007). Swaddling: A systematic death syndrome: A meta-analysis. Pediatrics, 137(6), 1-9. doi:10.1542/ review. Pediatircs, 120(4), e1097-e1106. doi:10.1542/peds.2006-2083 peds.2015-3275 van Sleuwen, B. E., L’Hoir, M. P., Engelberts, A. C., Busschers, W. B., Pediatric Orthopaedic Society of North America. (2015, April 28). Swad- Westers, P., Blom, M. A., …, Kuis, W. (2006). Comparison of behav- dling and developmental hip dysplasia position statement. Retrieved ior modifi cation with and without swaddling as interventions for from www.posna.org/news/swaddlingpositionstatementapril2015.pdf excessive crying. The Journal of Pediatrics, 149(4), 512-517. Pillai Riddell, R. R., Racine, N. M., Turcotte, K., Uman, L. S., Horton, R. doi:10.1016/j.jpeds.2006.06068 E., Din Osmun, L., …, Gerwitz-Stern, A. (2011). Non-pharmacological Wambach, K., & Riordan, J. (2016). Breastfeeding and human lactation management of infant and young child procedural pain. Cochrane (5th ed.). Burlington, MA: Jones & Bartlett Learning. Database of Systematic Reviews, (10). doi:10.1002/14651858. Wayse, V., Yousafzai, A., Mogale, K., & Filteau, S. (2004). Association of CD006275.pub2 subclinical vitamin D defi ciency with severe acute lower respiratory Ponsonby, A. L., Dwyer, T., Gibbons, L. E., Cochrane, J. A., & Wang, Y. G. infection in Indian children under 5 y. European Journal of Clinical (1993). Factors potentiating the risk of sudden infant death syn- Nutrition, 58(4), 563-567. doi:10.1038/sj.ejcn.1601845 drome associated with the prone position. The New England Jour- Wells, G. A., Shea, B., O’Connell, D., Peterson, J., Welch, V., Losos, M., nal of Medicine, 329(6), 377-382. & Tugwell, P. (2014). The Newcastle-Ottawa Scale (NOS) for assess- Richardson, H. L., Walker, A. M., & Horne, R. S. (2009). Minimizing the ing the quality of nonrandomized studies in meta-analyses. Re- risks of sudden infant death syndrome: To swaddle or not to trieved from www.ohri.ca/programs/clinical_epidemiology/oxford. swaddle? The Journal of Pediatrics, 155(4), 475-481. doi:10.1016/j. asp jpeds.2009.03.043 White, A. L., Carrara, V. I., Paw, M. K., Malika, Dahbu, C., Gross, M. M., …, Richardson, H. L., Walker, A. M., & Horne, R. S. (2010). Infl uence of McGready, R. (2012). High initiation and long duration of breastfeed- swaddling experience on spontaneous arousal patterns and auto- ing despite absence of early skin-to-skin contact in Karen refugees nomic control in sleeping infants. The Journal of Pediatrics, 157(1), on the Thai-Myanmar border: A mixed methods study. International 85-91. doi:10.1016/j.jpeds.2010.01.005 Breastfeeding Journal, 7(1), 19-31. doi:10.1186/1746-4358-7-19 Salter, R. B. (1968). Etiology, pathogenesis and possible prevention of Wilson, C. E. (2000). Cree infant care practices and sudden infant death congenital dislocation of the hip. The Canadian Medical Associa- syndrome. Canadian Journal of Public Health, 91(2), 133-136. tion Journal, 98(20), 933-945. Wisdorf-Houtkooper, K. K. (1997). The effi cacy of pediatric pain manage- Tuffnell, C. S., Petersen, S. A., & Wailoo, M. P. (1995). Prone sleeping ment techniques for infants during inoculation procedures (Doctoral infants have a reduced ability to lose heat. Early Human Develop- dissertation). Retrieved from CINAHL. (UMI No. PUZ9732889.) ment, 43(2), 109-116. Yamamuro, T., & Ishida, K. (1984). Recent advances in the prevention, Urnaa, V., Kizuki, M., Nakamura, K., Kaneko, A., Inose, T., Seino, K., & early diagnosis, and treatment of congenital dislocation of the hip Takano, T. (2006). Association of swaddling, rickets onset and bone in Japan. Clinical Othopaedics and Related Research, (184), 34-40. properties in children in Ulaanbaatar, Mongolia. Public Health, Yilmaz, A., Unsal, N., Celik, N., Karabel, M., Keskin, E., Tan, S., & 120(9), 834-840. doi:10.1016/j.puhe.2006.05.009 Aldemir, S. (2012). A perspective from the practice of swaddling by U.S. Preventive Services Task Force. (2014, October). Grade Defi nitions. Turkish mothers. Hippokratia, 16(2), 130-136. Retrieved from www.uspreventiveservicestaskforce.org/Page/Name/ Yurdakok, K., Yavuz, T., & Taylor, C. E. (1990). Swaddling and acute respi- grade-defi nitions ratory infections. American Journal of Public Health, 80(7), 873-875.

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